Journal of Patient Safety最新文献

{"title":"Rethinking Anesthesia Medication \"Errors\": The OR-SMART Patient Safety Learning Laboratory.","authors":"Ken R Catchpole, David M Neyens, James H Abernathy, Joshua Biro","doi":"10.1097/PTS.0000000000001384","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001384","url":null,"abstract":"<p><strong>Purpose: </strong>We combine the results of multiple studies to describe a systems engineering approach to a well-recognized patient safety problem. The goal of the Operating Room Systems-based Medication Administration error Reduction Team (OR-SMART) patient safety learning laboratory was to study the anesthesia medication work system to identify the characteristics of technologies and interventions that might feasibly reduce anesthesia medication errors.</p><p><strong>Scope: </strong>The work was conducted at 2 large urban academic medical centers: Johns Hopkins (JHU) and the Medical University of South Carolina (MUSC). We sampled across many different types of anesthesia work, understanding the challenges of work-as-done, and applying systems safety principles and evaluation frameworks.</p><p><strong>Methods: </strong>This was a mixed-methods study. Sources of data varied, with formal and informal interviews, formal and informal observations, video-based observations, hospital and national databases, and information from local incidents. Clinically embedded human factors professionals at both hospital sites facilitated informal sources of data. We explored the variable definitions of error; individual and organizational variability in decision-making; how syringes are used, stored, and moved within an operating room (OR); and used the Systems Engineering Initiative for Patient Safety (SEIPS) framework to model medication processes. We were able to identify more than 100 possible interventions, and then prioritized a few for development and testing.</p><p><strong>Results: </strong>We identified medication icon labels, a syringe holder hub, and workspace design guidelines as interventions for evaluation. Significant benefits of medication label icons were found in simulation and were highly utilized in practice. The syringe hub demonstrated high acceptability at one site but substantially less at another. A virtual reality-based evaluation of the OR design found that situational awareness, visual monitoring, and available workspace were subjectively improved.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144576783","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Primary Care Paramedic-administered Ketamine in British Columbia, Canada: A Patient Safety-focused Observational Study.","authors":"Tania Johnston, Christopher Mistiades, Roxane Beaumont-Boileau, Joseph Acker, Alan M Batt","doi":"10.1097/PTS.0000000000001390","DOIUrl":"10.1097/PTS.0000000000001390","url":null,"abstract":"<p><strong>Objectives: </strong>In Western Canada, British Columbia Emergency Health Services (BCEHS) aimed to enhance prehospital pain management by authorizing Primary Care Paramedics (PCP) to administer intranasal (IN) ketamine. The objective of this study is to describe patient safety implications of expanding PCP scope to include IN ketamine.</p><p><strong>Methods: </strong>This retrospective, observational study reviewed patient care records of the first 100 consecutive patient encounters where PCPs administered IN ketamine for pain between December 2020 and September 2021. Data analysis used the Canadian Quality and Patient Safety Institute and Rights of Medication Administration frameworks.</p><p><strong>Results: </strong>Of the 100 patients, 74% met the analgesia clinical practice guideline (CPG) criteria: adult, trauma, and moderate to severe pain. Most injuries (31%) involved extremities or hips/pelvis (18%). With 6 cases missing data, an 11.2% dosage error rate (>5 mg deviation) was identified. In 14 cases, PCPs did not contact mandatory clinical support and administered ketamine outside of the CPG. Documentation errors occurred in 25% of patient encounters, particularly with pain scores (20), patient weight (15), and vital signs (8), possibly indicating incomplete patient assessments. No instances of adverse patient outcomes resulting from dosing errors or missed consultations were observed throughout the study.</p><p><strong>Conclusions: </strong>This study highlights the safety implications of PCP-administered ketamine, including concerns about weight-based dosing, CPG compliance, and documentation standards. The key competencies of the Canadian Patient Safety Institute framework offer a foundation for addressing these safety concerns before expanding ketamine administration for broader PCP practice.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144576768","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Facilitators and Barriers Associated With the Use of Barcode Technologies in Drug Preparation and Administration in Hospital Settings-A Narrative Review of Qualitative Studies.","authors":"Sini Kuitunen, Laura Laakkonen, Katja Janhunen, Kirsi Kvarnström, Carita Linden-Lahti","doi":"10.1097/PTS.0000000000001381","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001381","url":null,"abstract":"<p><strong>Objectives: </strong>Barcode technologies are commonly used in hospital settings to improve medication safety. However, the implementation of these systems poses several challenges. This narrative review aims to synthesize qualitative studies exploring the facilitators and barriers associated with using barcode technologies in clinical environments.</p><p><strong>Methods: </strong>This review is grounded in the theory of systems-based risk management. A comprehensive literature search was conducted in November 2022 across 3 databases: CINAHL; MEDLINE (Ovid); and Scopus. Two independent reviewers utilized a predetermined SPIDER (Sample; Phenomenon of Interest; Design; Evaluation; Research type) tool for article selection by using Covidence software. The qualitative data from the selected studies were systematically summarized.</p><p><strong>Results: </strong>The search found 197 articles, of which 11 studies from 6 countries met the inclusion criteria. All included studies identified barriers, while 7 studies also highlighted facilitators. Seven common themes emerged as facilitators and barriers: efficacy; implementation; leadership; medication safety; process; technology; and user experience. Three themes-materials; system design; and work environment-were exclusively associated with barriers. Workarounds, such as bypassing barcoding, omitting process steps, and unauthorized process steps, were reported in 8 studies as responses to the barriers.</p><p><strong>Conclusions: </strong>This review underscores the complexity of implementing and maintaining high-leverage, technology-based systemic defenses in clinical practice. The findings provide a foundation for the improvement of the safety and usability of barcode technologies in hospital settings. Future research should focus on developing and testing interventions that address the identified barriers and enhance the facilitators to optimize the use of barcode systems.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144555488","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nursing Recommendations to Improve Discharge and Care Transitions From the Bedside.","authors":"Eve Emmanouilidou, Dhwani Krishnan, Elizabeth Kaplan, Vivien Moritz, Ishita Kaloti, Sachi Sengupta, Linda Czypinski, Erin Dowling, Wendy Simon, Anna Dermenchyan","doi":"10.1097/PTS.0000000000001382","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001382","url":null,"abstract":"<p><strong>Background: </strong>Discharge planning is a complex and critical process that ensures continuity of care, reduces postdischarge complications, and prevents hospital readmissions. Bedside nurses, central to this process, offer valuable perspectives on barriers to safe discharge and care transitions. This study aimed to identify common challenges in discharge planning and highlight nurse-driven solutions to improve patient safety.</p><p><strong>Methods: </strong>A cross-sectional survey was conducted with nurses from medical telemetry, cardiac observation, and short-stay observation units at a 520-bed tertiary academic teaching hospital from March 21 to April 30, 2022. Using the Agency for Healthcare Research and Quality's IDEAL Discharge Planning and Implementation Handbook as a framework, the survey assessed key challenges related to discharge and transitions of care. Participants rated their agreement with identified challenges, proposed solutions, and provided additional insights through an anonymous, 1-time survey.</p><p><strong>Results: </strong>Of 217 nurses contacted, 108 completed the survey (50% response rate). The majority identified significant barriers, including communication failures among care teams, care coordination gaps, medication reconciliation issues, and inadequate patient preparedness for discharge. Proposed solutions included implementing structured interprofessional communication protocols, enhancing discharge education strategies, and optimizing medication reconciliation processes.</p><p><strong>Conclusions: </strong>This study underscores the systemic and operational barriers to safe discharge from the perspective of bedside nurses. Implementing targeted, evidence-based interventions informed by frontline staff insights can improve patient outcomes, reduce preventable harm, and enhance the discharge experience for patients and families.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-07-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144545721","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association Between Surgeon Age and Patient Hemodynamic Instability in Pheochromocytoma Surgery: A Multicenter Cohort Study.","authors":"Sarah Chambers Skinner, Léa Pascal, Stéphanie Polazzi, Florian Fanget, Laurent Brunaud, Denis Collet, Bertrand Dousset, Fabrice Ménégaux, Eric Mirallié, Frédéric Sebag, Franck Zinzindohoue, Jean-Christophe Lifante, Antoine Duclos","doi":"10.1097/PTS.0000000000001387","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001387","url":null,"abstract":"<p><strong>Objective: </strong>To quantify the association between surgeon age and intraoperative hemodynamic instability (IHI) occurrence during pheochromocytoma surgery.</p><p><strong>Background: </strong>Surgeons must master technical and nontechnical skills to limit IHI occurrence during pheochromocytoma resection, a rare, complex surgery.</p><p><strong>Methods: </strong>This retrospective cohort study included data from adult patients who underwent pheochromocytoma surgery undertaken by surgeons aged 30 to 65 in 8 high-referral university hospitals in France from 01/01/2000 to 12/31/2016. Surgeon experience was quantified using surgeon's age at the time of surgery, and performance was evaluated using IHI occurrence. GEE logistic regression models, adjusted for potential confounders related to the patient and surgical procedure, were used to determine the probability of IHI according to surgeon age, independently of the surgeon-anesthesiologist duo and each surgeon's annual surgical volume.</p><p><strong>Results: </strong>Nine hundred ninety pheochromocytoma surgeries performed by 44 surgeons were analyzed. There was a concave relationship between surgeon age and IHI (P=0.012). Standardized rates of IHI were 71.7% (95% CI: 60.9%-82.6%) at 30 years, reached a minimum of 50.4% (45.9%-54.7%) at 48 years, and were 70.2% (55.7%-80.2%) at 65 years. Among low-volume surgeons, IHI occurrence was more likely in those aged 55 to 65 compared with those aged 45 to 55 [adjusted odds ratios=1.71 (1.04 to 2.80)]. Among high-volume surgeons, IHI was more likely to occur in surgeons aged 30 to 44 compared with those aged 45-55 [2.05 (1.10 to 3.83)].</p><p><strong>Conclusions: </strong>Our results suggest that in pheochromocytoma surgery surgeon performance could peak at mid-career, and then plateau and decline. Solutions that help surgeons maintain performance throughout their careers might be beneficial.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144545720","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The TRANS-SAFE Patient Safety Learning Laboratory: A Protocol for Systems Improvement for Psychosocial Safety in Transgender Care.","authors":"Tara N Cohen, Jennifer T Anger, Hanna Barton, Jill Blumenthal, Amanda Gosman, Falisha Kanji, Rai Khamisa, Jejo Koola, Priya Lewis, Maja Marinkovic, Bixby Marino-Kibbee, Maxwell Moore, Kyle Okamuro, Shanaya Sidhu, Victor Trasvina, Florin Vaida, Alan J Card","doi":"10.1097/PTS.0000000000001383","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001383","url":null,"abstract":"<p><strong>Objectives: </strong>This study aims to advance patient safety science by identifying and addressing the systemic causes of psychosocial harm among transgender and gender nonbinary (TGNB) individuals. The 4-year TRANS-SAFE patient safety learning laboratory (PSLL) will follow a 6-phase systems engineering approach to study ways to improve the safety of TGNB patients.</p><p><strong>Methods: </strong>This study involves conducting a systematic scoping review, interviews with patients, providers, and community members, and observations of TGNB patient and provider experiences to identify determinants of avoidable patient suffering. In addition, the PSLL will provide financial support for pre-doctorate and post-doctorate research scholars in the TGNB community. Human-centered solutions will be co-designed to mitigate psychosocial harm among TGNB individuals. Interventions will be developed through engagement with stakeholders in an iterative process of co-design and evaluation.</p><p><strong>Results: </strong>Interventions will be evaluated in real and simulated clinical environments for effectiveness, acceptability, usability, feasibility of implementation, and sustainability. A structural innovation of this PSLL is its focus on sustainment and dissemination, which will be facilitated through the development of a TRANS-SAFE certification process for health care organizations in partnership with the World Professional Association for Transgender Health (WPATH).</p><p><strong>Conclusions: </strong>This PSLL will address a fundamental gap in the science and practice of patient safety by assessing and addressing psychosocial patient harm in a high-risk population that has been too often neglected in the patient safety literature.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144486743","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Determinants of Harm in Fall Incidents in Hospital Settings With 200 or More Beds in Korea.","authors":"Youngmi Kang, Eunyoung Hong","doi":"10.1097/PTS.0000000000001385","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001385","url":null,"abstract":"<p><strong>Objective: </strong>Falls are a significant patient safety concern in hospital settings, often resulting in unintended harm. This study aimed to investigate the prevalence and risk factors for falls in Korean hospitals with 200 or more beds, analyzing 13,034 incidents reported to the Korean Patient Safety Reporting and Learning System from 2017 to 2021.</p><p><strong>Methods: </strong>The level of harm was classified into 3 categories: near-miss, adverse, and sentinel events. Hospital-related factors (hospital type, bed capacity, and location and time of fall incident) and patient-related factors (sex, age group, and admitting medical department) were included in the analysis. χ2 tests were used to evaluate differences in fall severity, and binary logistic regression identified factors associated with harmful incidents.</p><p><strong>Results: </strong>The study found that harmful falls were more likely to occur in nontertiary hospitals, particularly those with >500 beds, as well as in emergency departments. Furthermore, older female patients and those admitted to the internal medicine department are especially at risk.</p><p><strong>Conclusions: </strong>Based on the results of this study, especially in nontertiary hospitals with >500 beds, comprehensive strategies for preventing falls, including the promotion of patient safety culture, are needed to reduce fall occurrence and its associated disabilities.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-06-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144477527","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Assessing and Comparing Perceptions of Patient Safety Culture Among 4579 Health Care Staff in 13 General and Specialized Hospitals: A Cross-sectional Study.","authors":"Qian Lin, Dan Zhang, Calvin Kalun Or","doi":"10.1097/PTS.0000000000001377","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001377","url":null,"abstract":"<p><strong>Background: </strong>Although general and specialized hospitals have distinct roles and characteristics that can lead to differences in patient safety culture, there is a limited number of studies examining these differences.</p><p><strong>Objectives: </strong>To assess and compare health care staff's perceptions of patient safety culture between general and specialized hospitals.</p><p><strong>Methods: </strong>A cross-sectional questionnaire-based study of 4579 health care staff members, including physicians; nurses; other health care providers; and administrative staff, was conducted at 5 general and 8 specialized public hospitals in a major city in China. The Hospital Survey on Patient Safety Culture questionnaire was used to measure 12 dimensions of patient safety culture. The differences in perception of the 12 dimensions between general and specialized hospitals were analyzed using a χ2 test.</p><p><strong>Results: </strong>In general and specialized hospitals, positive ratings for \"communication openness, overall perceptions of patient safety, teamwork across departments, and handoffs and transitions\" ranged from 50% to 70%. Positive ratings for \"staffing\" and \"nonpunitive response to errors\" were <50%. Positive ratings for 8 of the dimensions analyzed were significantly lower in general hospitals than in specialized hospitals, with differences ranging from 2.23% to 4.4%. Within subgroups of health care staff, the dimensions with significant differences varied across professions. Specifically, among physicians, 9 out of 12 dimensions had lower positive ratings in general hospitals than in specialized hospitals, with differences ranging from 3.84% to 7.23%.</p><p><strong>Conclusions: </strong>General hospitals exhibited a more negative patient safety culture than specialized hospitals and thus require more proactive efforts to enhance their patient safety culture, especially among physicians. Both types of hospitals should urgently address issues related to \"staffing\" and \"nonpunitive response to errors.\"</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144286927","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Supporting Health Care Resilience Through \"Reflexive Spaces\" in Home Care Services: A Multiple Embedded Case Study.","authors":"Camilla Seljemo, Olav Røise, Eline Ree, Siri Wiig","doi":"10.1097/PTS.0000000000001375","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001375","url":null,"abstract":"<p><strong>Objectives: </strong>The aim of this study was to explore where and how managers facilitate arenas for collective reflections and knowledge sharing (\"reflexive spaces\") in homecare services during the COVID-19 pandemic. Moreover, we sought to understand how these \"reflexive spaces\" contributed to adaptations to challenges induced by the pandemic. Finally, we aimed to discuss how these spaces might incorporate resilience into health care.</p><p><strong>Methods: </strong>This multiple embedded case study includes interviews with health care staff (n=16) and managers at different system levels (n=21) from 4 Norwegian municipalities. The data were analyzed in accordance with reflexive thematic analysis.</p><p><strong>Findings: </strong>The analysis identified 2 overarching themes: (1) arenas for reflection, communication, and dialogue, and (2) establishing new solutions through collective reflection facilitated by managers. Managers who initiated dialogue and established arenas for reflection and communication were highlighted as important for discussing and sharing knowledge about challenges created by the pandemic. In these spaces, both managers and staff reflected, collaborated, and learned from each other and then designed a tactical and resilient response to the ongoing challenges.</p><p><strong>Conclusions: </strong>Managers had a key role as facilitators for \"reflexive spaces\" within and across levels of responsibilities. Moreover, managers had a mediating role in bridging knowledge and understanding across levels within the health care system. Using \"reflexive spaces\" as part of daily practice appeared as an important measure to balance demands and capacity and respond both to crises and to everyday challenges.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144286928","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Safety Outcomes Following Implementation of a Systematic Cataract Surgery Protocol at a Tertiary Referral Eye Center.","authors":"Joshua Ong, Beth K Hansemann, Paul P Lee, Jennifer S Weizer","doi":"10.1097/PTS.0000000000001376","DOIUrl":"https://doi.org/10.1097/PTS.0000000000001376","url":null,"abstract":"<p><strong>Purpose: </strong>To evaluate the longitudinal safety outcomes of incorrect intraocular lens (IOL) implantation using a standardized cataract surgery operating standard operating procedure (SOP) devised at a tertiary referral eye center. This evaluation represents a critical but underrepresented topic in ophthalmic literature.</p><p><strong>Methods: </strong>This was a quality improvement, retrospective analysis, and description of the Healthcare Failure Mode Effect and Analysis (HFMEA) and resultant SOP implemented in 2018 following incorrect IOL events. Analysis of subsequent safety events following implementation of the SOP and modifications/reassessments performed was analyzed. The main outcome measures were processes identified in the HFMEA and incorrect IOL safety events occurring following implementation of the SOP.</p><p><strong>Results: </strong>The HFMEA identified 170 processes/subprocesses steps, 177 potential failure modes, and 75 potential failure mode causes. Twenty-nine system vulnerabilities were identified through analysis of the failure mode causes. From 2018 to 2023, 8 additional incorrect IOL safety events occurred, which led to subsequent revisions of the SOP.</p><p><strong>Conclusion: </strong>Continuous reassessment of standardized protocols for cataract surgery is critical to ensure patient safety.</p>","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7,"publicationDate":"2025-06-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144250495","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}